The Parliamentary and Health Service Ombudsman said there was ‘significant variation’ in the quality of NHS investigations.
NHS investigations into care complaints ‘appalling’
More than a third of investigations into deaths or avoidable harm at hospitals found to be inadequate in ombusdsman’s review
Patients who complain about their care are being let down by “appalling” NHS investigations, a highly critical review has found.
More than a third of investigations into deaths or avoidable harm at hospitals were found to be “inadequate”, according to an investigation by the Parliamentary and Health Service Ombudsman (PHSO).
Families interviewed for the review complained they felt “belittled” and “misled” by medical staff who failed to listen to their concerns or give them straight answers.
Patients’ groups said the findings were “worrying” and suggested the lessons from recent hospital scandals had not been learnt.
Dr Katherine Rake, chief executive of the patients group Healthwatch England, said: “The ombudsman’s findings are worrying but sadly not surprising. Our research shows that tens of thousands of people every year are being failed by the NHS and yet never report it because they have no faith the complaints system will make any difference.
“Even worse, fewer than half of those that do find the energy and courage to raise their concerns ever hear the words ‘I’m sorry’.
“What we need is a complete overhaul of the complaints system that ensures every incident is properly investigated and learnt from, and that those affected are treated with the dignity they deserve.”
The investigation looked at 150 complaints regarding allegations that patients had died or suffered avoidable harm because of failings in their care.
It found that 28 of the 150 cases should have been investigated by the NHS as a Serious Untoward Incident (SUI), which is triggered to allow doctors to learn from past mistakes.
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But in the vast majority of these cases (71%) the hospital failed to carry out an SUI.
The Parliamentary and Health Service Ombudsman, Julie Mellor, said there was “significant variation” in the quality of NHS investigations.
She said: “Investigations weren’t carried out when they should have been and when they were carried out they did not find out or explain why failings happened.
“When people make a complaint that they have been seriously harmed they should expect it to be taken seriously and thoroughly investigated.
“The NHS must tackle the variation in the quality of its investigations but also needs to recognise when to initiate an investigation.
“When the NHS makes a mistake their duty is to investigate. These investigations shouldn’t be about attributing blame but should find out what happened and why in order to prevent the same mistakes from happening again. Our evidence too often shows this is not the case.”
In one case highlighted, a one-day-old baby, identified only as Baby F, was left with permanent brain damage because two doctors and a nurse made “serious mistakes” during blood transfusions.
But the hospital’s SUI investigation was “fundamentally flawed and did not identify glaring errors in the conduct and recording of the transfusion and ignored obvious explanations for what happened”, the ombudsman found.
In another case a 77-year-old man was admitted to hospital where he quickly deteriorated and died two days later from sepsis, a severe infection.
Unhappy with his care, his daughter complained, but the head of nursing who investigated failed to speak to clinical staff involved.
The ombudsman found medics failed to recognise just how sick the man was. The report states that while it was unable to conclude the man’s death could have been avoided, “the hospital missed an opportunity to give him the best chance of recovery by failing to give him more timely treatment”.
The interim findings are part of a major review into the way the NHS deals with complaints from patients and their families.
The full review and report will be released at a later date.
The review was announced following the Francis review, a damning report into the Mid Staffs hospital scandal which found that at least 1,200 patients died because of poor care at the hospital.
An ombudsman spokeswoman said: “Our casework shows that the quality of investigations carried out by the NHS into complaints about avoidable harm vary and can often be appalling.”
Caroline Abrahams, charity director of Age UK said: “Everyone who goes into hospital should feel confident that complaints about their care and treatment will be listened to and properly investigated.
“In addition, patient feedback is a true barometer of the calibre of care hospitals are providing. It is only by listening to their views and experiences that the NHS can ensure that care scandals that have blighted our hospitals too often do not happen in future.”
A Department of Health spokesman said: “We have set out the ambition to make the NHS the safest healthcare system in the world and know that listening to patients and staff is absolutely vital to improving care.
“That’s why we’ve made hospitals legally obliged to apologise to patients when mistakes do happen, introduced complaints handling as a crucial element of tougher hospital inspections and asked Robert Francis to produce an independent report on how to create a more open NHS culture.”
Dr Katherine Rake, chief executive of Healthwatch England, said: “The ombudsman’s findings are worrying, but sadly not surprising. Our research shows that tens of thousands of people every year are being failed by the NHS and yet never report it because they have no faith the complaints system will make any difference.
“Even worse, fewer than half of those that do find the energy and courage to raise their concerns ever hear the words ‘I’m sorry’.
“What we need is a complete overhaul of the complaints system that ensures every incident is properly investigated and learnt from, and that those affected are treated with the dignity they deserve.”
